MURRAY, UT - Federal inspectors documented multiple violations at Rocky Mountain Care - Cottage On Vine during a March 2025 health inspection, finding significant issues with medication administration, infection control protocols, and basic facility maintenance that potentially impacted resident safety and care quality.
Critical Medication Management Failures
The most serious violations centered on medication errors affecting three residents. In one case involving a dialysis patient, the facility repeatedly failed to administer a phosphorus-binding medication with meals as prescribed. The resident reported that his medication, which must be taken within 30 minutes of meals to be effective, was consistently delivered late or not at all.
"I was receiving the medication an hour to an hour and a half late or sometimes not at all," the resident told inspectors. Despite the facility's Director of Nursing marking the medication as high priority and flagging it in the electronic medical records system, administration problems persisted.
Phosphorus binders are critical medications for dialysis patients, as they prevent dangerous phosphorus buildup in the blood that can lead to bone disease, cardiovascular problems, and other serious complications. When taken improperly or late, these medications lose their effectiveness, potentially allowing phosphorus levels to reach harmful levels.
In a second medication error, a resident with osteomyelitis and chronic wounds did not receive scheduled intravenous antibiotic treatments on time. Documentation showed multiple instances where both Daptomycin and Micafungin were administered hours after their scheduled times, with some doses delayed by more than three hours.
Timely antibiotic administration is essential for treating serious infections like osteomyelitis, a bone infection that can become life-threatening if not properly managed. Delayed or inconsistent antibiotic levels in the bloodstream can reduce treatment effectiveness and potentially contribute to antibiotic resistance.
Infection Control and Antibiotic Stewardship Breakdown
Inspectors identified significant gaps in the facility's infection prevention protocols. In one case, a resident was prescribed antibiotics for a suspected urinary tract infection without proper diagnostic testing. The physician prescribed Levaquin based on the resident's symptoms and previous response to the medication, despite laboratory records showing the resident had bacteria resistant to that specific antibiotic.
This practice violates established antibiotic stewardship principles, which require diagnostic testing before prescribing antibiotics to ensure appropriate treatment and prevent the development of drug-resistant infections. The facility's infection preventionist acknowledged that prescribing antibiotics without proper testing "contributed to the development of antibiotic-resistant superbugs" and posed serious health risks to residents.
The facility also failed to maintain complete laboratory records for multiple residents, with critical test results missing from medical files. This documentation gap compromises the ability of healthcare providers to make informed treatment decisions and track the effectiveness of interventions.
Environmental and Safety Concerns
Inspectors documented concerning hygiene conditions in resident living areas. One resident's shower contained black substance along grout lines, white buildup on tile surfaces, circular rust stains on the floor, and persistent odors. Despite daily cleaning protocols, these conditions remained unchanged even after housekeeping staff applied bleach-based cleaners.
Poor bathroom hygiene in healthcare facilities can increase the risk of healthcare-associated infections, particularly concerning for residents with compromised immune systems or chronic medical conditions. Clean, sanitary bathing facilities are essential for maintaining resident dignity and preventing the spread of infectious diseases.
The kitchen also presented food safety violations, including improperly stored foods without date labels, staff working without required hair coverings, and malfunctioning dishwashing equipment that failed to achieve proper sanitization levels. When tested, the dish machine's sanitizer registered zero parts per million (PPM), well below the required levels for effective disinfection.
Reporting and Investigation Failures
Perhaps most concerning were violations related to abuse reporting and investigation procedures. In one incident, a resident reported that a nurse used profane language toward her, but staff failed to report the allegation to facility administration, the state survey agency, or adult protective services as required by federal regulations.
The staff member who received the complaint stated she wasn't sure if the incident qualified as abuse and failed to report it immediately. Federal regulations require all allegations of abuse to be reported within two hours, regardless of the staff member's assessment of the situation's severity.
Additionally, the facility could not provide complete investigation documentation for two previous abuse allegations, including cases involving claims of neglect and inappropriate conduct by nursing assistants. Proper documentation and investigation of all allegations is essential for resident protection and regulatory compliance.
Supply Management and Care Coordination Issues
The inspection revealed systemic problems with medical supply management that directly impacted patient care. One resident requiring a specialized 24 French suprapubic catheter was forced to wait for treatment because the facility lacked the correct size in inventory. Nursing staff instead used a smaller 22 French catheter without physician authorization.
This improvisation in medical care can compromise treatment effectiveness and patient safety. Suprapubic catheters must be precisely sized according to physician specifications to ensure proper drainage and minimize infection risk. Using incorrect equipment without medical authorization violates basic standards of care.
The facility's supply coordinator acknowledged that they should maintain adequate inventory of essential medical supplies at all times, particularly for residents requiring specialized equipment.
Additional Issues Identified
The inspection documented several other compliance concerns including incomplete Medicare coverage notifications, improper food portioning in the dietary department, missing vaccination documentation, and inadequate toileting programs for residents assessed as candidates for scheduled bathroom assistance.
Staff reported challenges with training temporary agency nurses, who were unfamiliar with facility protocols and individual resident needs. This staffing issue appeared to contribute to several of the medication timing problems and care coordination failures.
The facility's dietary department failed to follow established portion control measures, with kitchen staff estimating food quantities rather than using standardized measuring tools. This approach can result in inconsistent nutrition delivery and compromise efforts to meet residents' dietary requirements.
These violations collectively point to systemic issues with staff training, oversight procedures, and quality assurance protocols that require comprehensive corrective action to ensure resident safety and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rocky Mountain Care - Cottage On Vine from 2025-03-06 including all violations, facility responses, and corrective action plans.
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